Programming Connection

The PEP Program 

Clinique médicale l'Actuel
Montreal, Quebec
2010

How Does the Program Work?

Location

The PEP service is administered in a sexual health clinic that also provides HIV, STI and hepatitis B and C testing, treatment, counselling and support. 

Engagement and recruitment

To increase awareness of PEP and The PEP Program and to encourage people to use it, Clinique médicale l’Actuel relies heavily on word of mouth. The clinic runs an ongoing poster campaign in the gay community in Montreal. Posters are placed in kiosks throughout the gay village as well as in saunas (bathhouses) and bars. In addition, the program is promoted on the clinic website and in local gay publications. Posters are also placed in the clinic waiting room, which has proven to be effective in increasing inquiries about PEP.

The PEP Program promotional posters include information in plain language on:

  • What PEP is
  • How it works
  • Who is eligible to receive it

The posters also include a call to action targeting people who think they are at risk, telling them to hurry to the clinic if they’ve had a sexual encounter that may have put them at risk.

The Program

Screening a person who wishes to participate in The PEP program includes four steps:

  1. Assessing an individual’s risk of HIV infection
  2. Providing pre-PEP support and education
  3. Administering PEP and offering treatment support
  4. Offering post-PEP testing, counselling and education

Step 1: Initial assessment for the risk of HIV infection

A nurse meets confidentially with each client who visits the clinic to participate in The PEP Program to determine if he/she is in need of PEP based on three criteria:

  1. The individual is, to the best of his/her knowledge, currently HIV negative.
  2. The individual has potentially been exposed to HIV through a high-risk activity.
  3. The exposure has taken place within the previous 72 hours. 

During this initial meeting, the nurse determines whether or not the client fulfils each criteria based on their responses to guided questions. If a client is determined to have only a minimal risk for having been exposed to HIV (e.g., he/she has engaged in protected sex only), the person will be not be given access to PEP, but are offered information on HIV and STI transmission, risk factors and safer behaviour. The client is also offered vaccinations, such as hepatitis A and B, and testing for syphilis, hepatitis A, B and C, gonorrhea and chlamydia.  

If the nurse determines that the person is eligible for PEP, they will move on to Step 2.

Step 2: Second assessment, pre-PEP support and education

The physician who can prescribe PEP meets with the client to:

  • Assess his/her eligibility for PEP
  • Explain the pros and cons of PEP (i.e., its potential efficacy and side effects)
  • Provide safer-sex counselling and HIV transmission information
  • Promote the use of safer sex during as well as after PEP
  • Administer STI and HIV testing
  • Administer blood tests for liver and kidney function to ensure that the client is able to take PEP medications

The physician explains that the HIV test may not show a positive result if exposure occurred within the past two months (also known as the “window period”).

If the client is eligible for PEP, the physician will explain the treatment, potential side effects and importance of adhering to the full 28-day prescription. The physician will also explain that additional exposure to HIV during PEP treatment may reduce the treatment’s efficacy, so safer behaviours such as continued use of condoms during sex are essential. The physician will emphasize that even if adherence is perfect and no additional exposures occur there is still no guarantee that infection will be prevented.

Step 3: Administering PEP

A person who is determined to use PEP and who understands the implications of taking PEP will be given a written prescription to be presented at a pharmacy for the 28-day regimen of antiretroviral medications. Currently, the clinic uses Kaletra and Truvada because they cause fewer side effects than other available drugs. See Other Useful Resources for more information on antiretroviral medication.

The cost of the medication is either covered by private insurance (if the patient has insurance) or the Quebec provincial drug plan, which covers the majority of the prescription costs. Most provincial health plans in Canada do not cover PEP medications for non-occupational exposure to HIV.

Support during treatment: Patients are encouraged to follow up with the clinic during the 28-day treatment if they want to discuss side effects and challenges to adherence. The clinic does not contact them.

Step 4: Follow up – HIV testing, counselling and education after the completion of PEP

After the completion of the treatment, the client must return to the clinic for follow-up HIV testing to determine if they have seroconverted. Follow-up visits also include counselling, safer-sex education and support, including, when relevant, referrals to addiction and mental health services.

The client will return to the clinic two times for HIV testing:

  • One month after the first visit (just after the completion of the treatment)
  • Three months after finishing the treatment

If they test positive, they are referred to a physician within the clinic to discuss how to proceed with their care.